Adjuvant bleomycin, etoposide and cisplatin in pathological stage II non-seminomatous testicular cancer. the Indiana University experience

Overcoming Cancer Multi-drug Resistance (MDR): Reasons, mechanisms, nanotherapeutic solutions, and challenges

Multi-drug resistance (MDR) in cancer cells, either intrinsic or acquired through various mechanisms, significantly hinders the therapeutic efficacy of drugs. Typically, the reduced therapeutic performance of various drugs is predominantly due to the inherent over expression of ATP-binding cassette (ABC) transporter proteins on the cell membrane, resulting in the deprived uptake of drugs, augmenting drug detoxification, and DNA repair. In addition to various physiological abnormalities and extensive blood flow, MDR cancer phenotypes exhibit improved apoptotic threshold and drug efflux efficiency. These severe consequences have substantially directed researchers in the fabrication of various advanced therapeutic strategies, such as co-delivery of drugs along with various generations of MDR inhibitors, augmented dosage regimens and frequency of administration, as well as combinatorial treatment options, among others. In this review, we emphasize different reasons and mechanisms responsible for MDR in cancer, including but not limited to the known drug efflux mechanisms mediated by permeability glycoprotein (P-gp) and other pumps, reduced drug uptake, altered DNA repair, and drug targets, among others. Further, an emphasis on specific cancers that share pathogenesis in executing MDR and effluxed drugs in common is provided. Then, the aspects related to various nanomaterials-based supramolecular programmable designs (organic- and inorganic-based materials), as well as physical approaches (light- and ultrasound-based therapies), are discussed, highlighting the unsolved issues and future advancements. Finally, we summarize the review with interesting perspectives and future trends, exploring further opportunities to overcome MDR.

Retrospective Evaluation of a Combination of Carboplatin and Bleomycin for the Treatment of Canine Carcinomas

Carboplatin is a chemotherapy agent widely used in veterinary oncology to treat various types of tumors including carcinomas. Carboplatin has previously been used in combination with 5-Fluoro uracil (5-FU) or gemcitabine for the treatment of various carcinomas. Bleomycin is a chemotherapy drug commonly used in humans, but its use has been uncommonly reported in dogs. The combination of carboplatin and bleomycin chemotherapy treatment has never been reported in dogs. Dogs diagnosed with carcinoma and treated with a combination of carboplatin and bleomycin, at a single veterinary referral center, were retrospectively evaluated. Thirty patients met the inclusion criteria. The dose of carboplatin ranged from 200–250 mg/m2 (median 240 mg/m2) and the dose of bleomycin from 15–20 IU/m2 (median 15 IU/m2). The treatment with carboplatin and bleomycin was well tolerated, with sixteen patients (53%) developing side effects. Thirteen patients (46%) developed gastrointestinal signs and nine dogs (30%) developed hematological abnormalities. The most common side effects were grade-1 hyporexia and grade-1 neutropenia. Grade-2 neutropenia was rarely observed, and only one patient developed grade-3 neutropenia. None of the dogs developed grade-4 adverse events, or required hospitalization, or died due to the treatment. No signs of chronic side effects, including pulmonary toxicity, were observed. Objective response was observed in 24% of the cases (six partial responses) and 76% of cases achieved clinical benefit (partial response+ stable disease). Clinical signs improved in 24 of the 30 cases (80%). The main aim of this study was to evaluate the safety of bleomycin and carboplatin in combination for the treatment of various types of carcinomas. The combination of bleomycin and carboplatin appears safe and potentially effective for some types of carcinomas. Larger prospective studies are needed to confirm the safety and efficacy of combined carboplatin and bleomycin.

Thymoquinone ameliorates bleomycin-induced reproductive toxicity in male Balb/c mice

Bleomycin (BL) is a powerful chemotherapy drug that has devastating effects on spermatogenic function and may make cancer survivors at risk of infertility. Protective effects of thymoquinone (TQ), a phytochemical compound with antioxidant and anticancer influences, were investigated on sperm parameters, testicular structures, and sexual hormones in BL-treated mice. Forty-eight adult male Balb/c mice were randomly divided into six groups. Control group received normal saline; BL group received 10 mg/kg BL; TQ7.5 group received 7.5 mg/kg TQ; TQ15 group received 15 mg/kg TQ; BL+TQ7.5 group received 10 mg/kg BL and 7.5 mg/kg TQ; BL + TQ15 group received 10 mg/kg BL and 15 mg/kg TQ. BL was intraperitoneally used every day through 35 days, and TQ was intraperitoneally injected 3 days before administration of BL and continued twice per week for 35 days. Results showed that BL significantly decreased count, viability, morphology, maturity, and progressive movement of sperm, testosterone, seminiferous tubule diameters, the ratio of testis weight to body weight, number of spermatogonia, spermatocytes, spermatids, and Sertoli cells per tubule, and expression of Bcl2l1 and Bcl2l1/Bax ratio, and increased the non-progressive movement and immotile sperm, intermediate and immature sperm, LH, FSH, and malondialdehyde levels, and tunica albuginea thickness compared to the control group (p < .05). TQ at a level of 7.5 mg/kg ameliorated BL-induced toxicity on measured parameters and returned most of them to the level of the control group. These data suggested TQ in a dose-dependent manner may have positive effects on BL-induced toxicity of the testis in mice model.

Testicular Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Testicular cancer is relatively uncommon and accounts for <1% of all male tumors. However, it is the most common solid tumor in men between the ages of 20 and 34 years, and the global incidence has been steadily rising over the past several decades. Several risk factors for testicular cancer have been identified, including personal or family history of testicular cancer and cryptorchidism. Testicular germ cell tumors (GCTs) comprise 95% of malignant tumors arising in the testes and are categorized into 2 main histologic subtypes: seminoma and nonseminoma. Although nonseminoma is the more clinically aggressive tumor subtype, 5-year survival rates exceed 70% with current treatment options, even in patients with advanced or metastatic disease. Radical inguinal orchiectomy is the primary treatment for most patients with testicular GCTs. Postorchiectomy management is dictated by stage, histology, and risk classification; treatment options for nonseminoma include surveillance, systemic therapy, and nerve-sparing retroperitoneal lymph node dissection. Although rarely occurring, prognosis for patients with brain metastases remains poor, with >50% of patients dying within 1 year of diagnosis. This selection from the NCCN Guidelines for Testicular Cancer focuses on recommendations for the management of adult patients with nonseminomatous GCTs.

Surgical treatment of metastatic germ cell cancer

Among young men between the ages of 15 and 40 years, germ cell cancer is the most common solid tumor [1]. The worldwide incidence of germ cell cancer is 70 000 cases. Compared to all solid tumors of men, germ cell cancer accounts for 1% of all male tumors. Nevertheless, the mortality of this rare tumor entity is about 13% since 9507 patients died worldwide of germ cell cancer. The improvement in survival of germ cell cancer patients is due to a multimodal treatment of germ cell cancer including cisplatin-based chemotherapy and surgery leading to higher cure-rates even in advanced stages [1], whereas the increasing incidence of germ cell cancers cannot be thoroughly explained. In this article we review the current indications for surgery in metastatic germ cell cancers, highlight the strength and weaknesses of techniques and indications and raise the question how to improve surgical treatment in metastatic germ cell cancer.

Adjuvant Chemotherapy With Etoposide Plus Cisplatin for Patients With Pathologic Stage II Nonseminomatous Germ Cell Tumors

PURPOSE

The relapse rate after primary retroperitoneal lymph node dissection (RPLND) for patients with pathologic stage (PS) IIA nonseminomatous germ cell tumors (NSGCTs) is 10%-20% but increases to ≥ 50% for PS IIB disease. We report our experience with 2 cycles of adjuvant etoposide plus cisplatin (EP×2) after therapeutic primary RPLND.

PATIENTS AND METHODS

All patients with PS II NSGCT seen at Memorial Sloan Kettering Cancer Center from March 1989 to April 2016 and who were planned to receive EP×2 were included. Each cycle consisted of cisplatin 20 mg/m2 and etoposide 100 mg/m2 on days 1 through 5 at 21-day intervals. Demographic characteristics, histopathologic features, therapeutic and survival outcomes were recorded.

RESULTS

Of 156 patients, 30 (19%) had pathologic N1, 122 (78%) had pathologic N2 (pN2), and 4 (3%) had pathologic N3 (pN3) disease. The median number of involved lymph nodes was 3 (range, 1-37 nodes), and the median size of the largest involved node was 2.0 cm (range, 0.4-7.0 cm); extranodal extension was present in 69 patients (45%). Embryonal carcinoma was the most frequent RPLND histology, present in 143 patients (92%). One hundred fifty patients (96%) received EP×2, five received EP×1 and one received EP×4. With a median follow-up of 9 years, 2 patients (1.3%; 1 patient each with pN2 and pN3 disease) experienced relapse; both patients remain continuously disease free at more than 5 and 22 years after salvage chemotherapy. Three patients died, all unrelated to NSGCT, yielding 10-year disease-specific, relapse-free, and overall survival rates of 100%, 98%, and 99%, respectively.

CONCLUSION

Adjuvant EP×2 for PS II NSGCT is highly effective, has acceptable toxicity, and incurs less drug cost than 2 cycles of bleomycin, etoposide, and cisplatin. Inclusion of bleomycin in this setting is not necessary.

Current management and management controversies in early- and intermediate-stage of nonseminoma germ cell tumors

Early stage nonseminomatous germ cell tumor (NSGCT) remains a treatable disease, with stage I cancer specific survival exceeding 95%. Using a risk-adapted approach; active surveillance (AS), adjuvant chemotherapy, and retroperitoneal lymph node dissection (RPLND) all options for treatment; with surveillance being increasingly used. With persistently elevated markers (stage IS), chemotherapy remains the hallmark of treatment. Management of stage II NSGCT varies based on status of tumor markers. With negative markers, both induction chemotherapy and upfront RPLND remain options. Management of a residual mass <1 cm after chemotherapy remains controversial, with AS and nerve-sparing RPLND considered options. The development of miR-371a-3p microRNA shows promise a novel biomarker for testicular cancer (GCT). Despite controversies in management, cures for NSGCT are achievable in 95-99% of patients.

Systemic therapy for primary and extragonadal germ cell tumors: prognosis and nuances of treatment

Testicular germ cell tumors are the most common solid tumors in young men. These cancers represent a success story of modern medicine in our ability to cure young patients and offer decades of life, with a 5-year survival rate of approximately 95%. This review outlines the staging and risk classification of testicular cancers, and reviews the current state of knowledge and standard of care for the systemic treatment of testicular germ cell tumors with chemotherapy, focusing on the relevant clinical data supporting each treatment regimen. This review also briefly highlights current areas of active investigation, notably in the relapsed and refractory setting, including ongoing clinical trials.

Management of Stage II Germ Cell Tumors

There are several treatment approaches for stage II germ cell tumors (GCTs), and a thorough understanding of the staging classification and histologic differences in tumor biology and therapeutic responsiveness is critical to determine an effective, multimodal management strategy that involves urologists, medical oncologists, and radiation oncologists. This article discusses contemporary management strategies for stage II GCTs, including chemotherapy, radiotherapy, retroperitoneal lymph node dissection (RPLND), and surveillance. Patient selection, histology, and extent of lymphadenopathy drive management, and, as both treatment and detection strategies continue to emerge and be refined, the management of patients with stage II GCT continues to evolve.

Adjuvant Therapy for Stage IB Germ Cell Tumors: One versus Two Cycles of BEP

Testicular germ cell tumours are the commonest tumours of young men and are broadly managed either as pure seminomas or as 'nonseminomas'. The management of Stage 1 nonseminomatous germ cell tumours (NSGCTs), beyond surgical removal of the primary tumour at orchidectomy, is somewhat controversial. Cancer-specific survival rates in these patients are in the order of 99% regardless of whether surveillance, retroperitoneal lymph node dissection, or adjuvant chemotherapy is employed. However, the toxicities of these treatment modalities differ. Undertreating those destined to relapse exposes them to the potentially significant toxicities of 3-4 cycles of bleomycin, etoposide, and cisplatin (BEP) chemotherapy. Conversely, giving adjuvant chemotherapy to all patients following orchidectomy results in overtreatment of a significant proportion. Therefore, the challenge lies in delineating the patient population who require adjuvant chemotherapy and in determining how much chemotherapy to give to adequately reduce relapse risk. This chapter reviews the factors to be considered when adopting a risk-adapted strategy for giving adjuvant chemotherapy in Stage 1B NSGCT sand discusses the data regarding the number of BEP cycles to administer.

Management of Stage I Nonseminomatous Germ Cell Tumors

Testis cancer represents the model for a curable malignancy. Although there is consensus about the appropriate management of metastatic (clinical stage [CS] IIC-III) nonseminomatous germ cell tumor (NSGCT) in terms of the chemotherapy regimens, number of cycles, and the surgical resection of postchemotherapy residual masses, there remains controversy regarding the appropriate management of low-stage NSGCT (CSI-IIB). In this article, the benefits and drawbacks of each treatment option are reviewed; an evidence-based approach when confronted with such a patient and how to best select a treatment avenue based on the patient's clinical and pathologic features are also discussed.

Current update of management of clinical stage I non seminomatous germ cell tumors of testis

The management of patients with testicular germ cell tumors (GCT) has evolved significantly over the past 30 years with cure rates approaching nearly 100% for low-stage disease and more than 80% for advanced disease. Controversy surrounds about ideal management of clinical stage I non seminomatous germ cell tumors (CS I NSGCT) of the testis due to multiple treatment options available with more or less equal efficacy. Nerve-sparing retroperitoneal lymph node dissection (RPLND), adjuvant chemotherapy with two cycles of bleomycin, etoposide, and cisplatin , or surveillance have all achieved long-term survival in nearly 100% of patients with clinical stage I NSGCT. Retroperitoneal lymph node dissection is still favoured as the therapy of choice for clinical stage I non-seminomatous germ cell tumors in many centres, but as risk factors for the primary tumor have become better understood, surveillance and risk-adapted therapy, including surveillance for low-risk patients and adjuvant chemotherapy for the high-risk group, is now being considered a therapeutic option. The objective of this study is to review current developments in the management of CS I NSGCT testis with emphasis on risk stratification and treatment recommendations.

Management options for stage 1 nonseminomatous germ cell tumors of the testis

Management of clinical stage I non seminomatous germ cell tumor includes surveillance, primary chemotherapy and retroperitoneal lymph node dissection. Stratifying clinical stage I disease to high-and low-risk groups for harboring micrometastic retroperitoneal disease (pathologic stage B) is based on pathologic characteristics of the primary tumor. The presence of embryonal dominant histology and lymphovascular invasion (high-risk group) predicts for a 50% incidence of retroperitoneal disease. Low-risk group, the absence of either factor, predicts a 20% chance of retroperitoneal disease. Irrespective of risk classification, all treatment modalities have equal survival rates of 99% to 100%, and differ only in their unique short and long-term modalities. The mode of treatment in clinical stage I disease should remain patient driven and is guided by the perceived morbidities of each therapy.

Defining the Optimal Treatment for Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer Using Decision Analysis

Purpose

There is equipoise regarding the optimal treatment of clinical stage (CS) I nonseminomatous germ cell testicular cancer (NSGCT). Formal mechanisms that enable patients to consider cancer outcomes, treatment-related morbidity, and personal preferences are needed to facilitate decision making between retroperitoneal lymph node dissection (RPLND), primary chemotherapy, and surveillance.

Methods

Decision analysis was performed using a Markov model that incorporated likelihoods of survival, treatment-related morbidity, and utilities for seven undesired post-treatment health states to estimate the quality-adjusted survival (QAS) for each treatment option. Utilities were obtained from 24 hypothetical NSGCT patients using a visual analog (rating) scale and standard gamble.

Results

Overall, QAS associated with each treatment was high and differences in QAS were small. Surveillance was the preferred intervention for patients with a risk of relapse less than 33% and 37% using the rating scale and standard-gamble method of utility assessment, respectively. Active treatment was favored over surveillance for patients with relapse risk on surveillance greater than 33% and 37% by the rating scale (RPLND preferred) and standard-gamble methods (primary chemotherapy preferred), respectively. Substantial differences in average utilities were seen depending on the method used. By the rating scale, patients substantially devalued life in six of seven undesired health states but they were surprisingly tolerant of treatment-related morbidity using standard gamble.

Conclusion

A decision model has been developed for CS I NSGCT that estimates QAS for RPLND, primary chemotherapy, and surveillance by considering cancer outcomes, morbidity, and patient preferences. Surveillance was the preferred intervention for all except those patients at high risk for relapse.

Surgical management of low-stage nonseminomatous germ cell testicular cancer

The optimal treatment of low-stage nonseminomatous germ cell testicular cancer (NSGCT) is controversial. For clinical stage (CS) I NSGCT, retroperitoneal lymph node dissection (RPLND), two cycles of chemotherapy and surveillance are all accepted treatment options. For CS IIA-B, standard treatments include RPLND (+/- adjuvant chemotherapy) and induction chemotherapy (+/- RPLND). The long-term survival rate is >97% for CS I and 95% for CS IIA-B NSGCT, regardless of the treatment received. The risk of retroperitoneal metastasis varies by clinical stage (25-35% for CS I, 65-85% for CS IIA-B), and the presence of lymphovascular invasion and percentage of embryonal carcinoma in the primary tumour. Patients with elevated serum tumour markers (STMs) and adenopathy of >3 cm are at high risk of having occult systemic disease. Compared with chemotherapy, RPLND is associated with a considerably more favourable long-term morbidity profile and is the most effective method for controlling the retroperitoneum. Surveillance is associated with the lowest risk of long-term complications. As such, we favour surveillance for low-risk CS I, induction chemotherapy for those at high risk of systemic disease (elevated STM, adenopathy >3 cm), and RPLND for all others. Modified template dissections reduce the risk of ejaculatory dysfunction, but might increase the risk of local recurrence. Therefore, we favour a full-bilateral template dissection with nerve-sparing in patients with low-stage NSGCT. The therapeutic efficacy of laparoscopic RPLND is not proven and currently should be considered a staging procedure only. Adjuvant chemotherapy after RPLND is typically restricted to patients with pathological stage N2-3 disease.

Risk-adapted management for patients with clinical stage I non-seminomatous germ cell tumour of the testis

Testis cancer is the most common cancer in young men and its incidence continues to rise. Even if prognosis is considered as good, a group with bad prognosis still remains. We aimed to evaluate whether two courses of chemotherapy after orchiectomy in patients with clinical stage I, non-seminomatous germ cell testicular tumour at high risk of relapse, will spare patients additional chemotherapy or surgery. High-risk patients had one or more of the following: preorchiectomy alpha-fetoprotein level of 80 ng/dl, 80% embryonal cell carcinoma or greater, vessel invasion in the primary tumour and tumour stage pT2 or greater. Low-risk patients had none of these factors or had 50% teratoma or more without vessel invasion. High-risk patients were offered two 21-day courses of outpatient chemotherapy consisting cisplatin, etoposide and bleomycin (BEP). Low-risk patients were observed. Of the 108 patients, we classified 71 as high risk and 37 as low risk of relapse. All of the high-risk patients received two courses of BEP chemotherapy. Low-risk patients were kept on close-up. The median follow-up was 26 months (range 10-60). Of the 71 patients in high-risk group, 3 relapsed with viable cancer and required additional chemotherapy and 1 patient with normal biomarkers and a late-appearing mass underwent retroperitoneal lympadenectomy for mature teratoma. All 4 relapsed patients were in high-risk group and presently they are free of disease. None of the 37 patients at low risk of recurrences developed relapse. We recommend two courses of adjuvant chemotherapy after postorchiectomy for high-risk patients with stage I non-seminomatous germ cell tumour of the testis. Adjuvant chemotherapy for these patients results in a low relapse and morbidity, wich compares favourably with the results of surveillance or RPLND. This well-tolerated approach may spare patients additional surgery or protracted chemotherapy, reduce the cost and eliminate the compliance problems associated with intensive follow up of high-risk patients.

Nonrandomized comparison of primary chemotherapy and retroperitoneal lymph node dissection for clinical stage IIA and IIB nonseminomatous germ cell testicular cancer

PURPOSE Patients with clinical stage (CS) IIA and IIB nonseminomatous germ cell tumor (NSGCT) with adenopathy more than 2 cm, multiple masses, elevated serum tumor markers, or disease outside the primary landing zone have increasingly been recommended to receive primary chemotherapy over time at our institution. The impact of these selection factors on the outcome of patients managed primarily by retroperitoneal lymph node dissection (RPLND) or chemotherapy was examined. PATIENTS AND METHODS Between 1989 and 2002, 252 patients with CS IIA and IIB NSGCT were referred to our institution for initial management, of whom 136 underwent RPLND and 116 received chemotherapy and postchemotherapy RPLND. Patient information was obtained from a prospective RPLND database. Results Proportionately more patients received chemotherapy over time (22% in 1989 to 1993 v 68% in 1999 to 2002), and the relapse-free survival (RFS) subsequently improved from 84% (1989 to 1998) to 98% (1999 to 2002; P = .004) without increasing the proportion who received any chemotherapy (70% v 79%; P = .16). By increasingly selecting patients with adverse features for primary chemotherapy, the RFS after RPLND improved from 78% to 100% (P = .019), but rates of pathologic stage II and retroperitoneal teratoma were unaffected. Retroperitoneal histology and RFS did not change over time for chemotherapy patients. Primary chemotherapy was associated with improved RFS compared with RPLND (98% v 79%; P < .001), but disease-specific survival did not differ significantly (100% v 98%; P = .3). CONCLUSION Patient selection factors have significantly improved the outcome of patients with CS IIA and IIB NSGCT without substantially increasing the proportion of patients exposed to chemotherapy.

[Testis germ cell tumours: which chemotherapy, for which patients?]

Germ cell tumours of the testis are curable disease. Two different pathological subtypes are observed: seminoma and non-seminoma. Two tumour stages have been defined: the disease limited to the testis and the advanced disease. In the latter group, the prognosis is established by a specific classification based on the level of serum tumour marker and the location of the metastases. The most active first line chemotherapy is a combination of bleomycine, etoposide and cisplatine. Patients with good prognostic factors receive three cycles of this regimen; patients with poor-risk characteristics receive four cycles of the same regimen. The strategy in non-seminoma patients is to give a first-line chemotherapy adapted to the risk factors, then to complete surgical exeresis of all residual disease. Patients with stage I disease may receive two cycles of the same regimen. The strategy for advanced seminoma is to give first-line good-risk chemotherapy followed by a close observation and in several selected cases a surgical removal of all residual disease. Patients with stage I disease may receive one cycle of carboplatin. Salvage chemotherapy is based on the combination of ifosfamide, cisplatine and either vinblastine or paclitaxel.

Management of Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer

The optimal management of patients who have clinical stage I nonseminomatous germ cell tumors remains controversial. Surveillance, retroperitoneal lymph node dissection (RPLND), and chemotherapy with two cycles of bleomycin-etoposide-cisplatin are established treatment options and all are associated with long-term cancer control rates of 97% or greater. Studies have consistently identified the presence of lymphovascular invasion and a predominant component of embryonal carcinoma in the primary tumor as risk factors for occult metastatic disease in these patients. Patients who do not have these risk factors are optimally managed by active surveillance given the low risk for relapse. For patients at high risk for relapse and who are not candidates for surveillance, we believe the evidence supports RPLND over primary chemotherapy.

Adjuvant Chemotherapy for Stage II Nonseminomatous Germ Cell Tumors

Management options for patients who have stage II nonseminomatous germ cell cancer, completely resected at retroperitoneal lymph node dissection (RPLND), include two cycles of adjuvant cisplatin-based chemotherapy or close surveillance, with chemotherapy reserved for patients who relapse. Both options are associated with cure in an equally high percentage of patients. The choice of options is influenced by the extent of the tumor resected and patient compliance. Surveillance is a strong consideration for patients who have low-volume nodal disease at RPLND because the relapse proportion is 30% or less. In contrast, patients who have high-volume nodal involvement at RPLND have a relapse rate of 50% to 90% with surveillance alone, and adjuvant chemotherapy is the preferable option in this group.

Long-term outcome of retroperitoneal lymph node dissection in the management of testis cancer

In low volume testicular cancer, (clinical stage A/B1) retroperitoneal lymph node dissection has maintained its therapeutic benefit while minimizing morbidity with the reduction of the surgical template from a full bilateral dissection to a unilateral nerve-sparring surgery. The optimal treatment for low stage disease is largely patient driven with surgery and surveillance considered the primary treatment modalities. In the post chemotherapy population, patients with complete radiographic resolution of retroperitoneal disease are observed at Indiana University as the relapse rate in this population is approximately 5%. Residual masses after chemotherapy should be resected. A modified post chemotherapy dissection is adequate in low volume disease restricted to the primary landing zone of the affected testicle. In chemo-refractory disease, aggressive surgery provides a 5 year survival of 31% for patients with active cancer. Excluding chemo-naïve patients, late relapse disease is managed surgically with 50% being cured of disease.

Management of patients with low-stage nonseminomatous germ cell testicular cancer

Management options for patients with clinical stage (CS) I nonseminomatous germ cell testicular cancer (NSGCT) include surveillance, retroperitoneal lymph node dissection (RPLND), or two cycles of bleomycin-etoposide-cisplatin (BEP x 2) chemotherapy. The optimal management of these patients is controversial, as cure rates of 97% or greater are reported with each of these treatment modalities. Patients without evidence of lymphovascular invasion, a predominant component of embryonal carcinoma, or advanced pathologic (p) T stage (pT 2 or greater) are at low risk for occult metastases and are optimal candidates for surveillance. Compliance with diagnostic testing and imaging is essential for a successful surveillance strategy to detect and treat metastases at an early stage. For patients who are not candidates for surveillance, RPLND offers several advantages over chemotherapy. RPLND alone is curative in 50% to 80% of CS I patients with pathologic stage (PS) II, and an estimated 75% of CS I patients avoid chemotherapy (as adjuvant therapy or for treatment of relapse). Virtually all patients are cured following two cycles of adjuvant chemotherapy for PS II disease, which is reserved for patients with high-volume (PN2-3) retroperitoneal disease. The poor outcome of patients with late retroperitoneal recurrence from unresected, chemorefractory germ cell testicular cancer indicates that RPLND is a vital component to the long-term cure of patients with NSGCT. Approximately 20% to 30% of patients with PS II disease have retroperitoneal teratoma (which is chemoresistant), and an estimated 5% of PS II patients have chemoresistant viable cancer following BEP x 2 as primary therapy. When RPLND is omitted, these patients are at risk for late recurrence with potentially lethal consequences. Patients who relapse after RPLND are "chemotherapy-naïve" and cured in virtually all cases with good-risk chemotherapy regimens. When nerve-sparing techniques are employed to preserve ejaculation, RPLND is also associated with a more favorable long-term toxicity profile compared with chemotherapy. In the absence of conclusive evidence from a randomized trial, we believe RPLND is the treatment of choice for patients with CS I NSGCT who are not candidates for surveillance, as it offers the greatest likelihood of long-term cure with considerably less morbidity than primary chemotherapy.

Retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer: impact of patient selection factors on outcome

PURPOSE

To investigate the impact of patient selection criteria on the outcome of patients with nonseminomatous germ cell testicular cancer (NSGCT) treated by primary retroperitoneal lymph node dissection (RPLND). Since 1999, our criteria have excluded patients with persistent postorchiectomy elevation of serum tumor markers (STM) or clinical stage (CS) IIB disease from RPLND.

PATIENTS AND METHODS

Between 1989 and 2002, 453 patients underwent primary RPLND at our institution for CS I to IIB NSGCT. Patient information was obtained from a prospective database. Retroperitoneal pathology and relapse rates were compared for patients treated before and after application of the current selection criteria in 1999.

RESULTS

By excluding patients with elevated STM or CS IIB disease after 1999, the proportion of pathologic stage II patients with low-volume (pN1) retroperitoneal disease increased significantly (40% before 1999 v 64% after 1999; P = .01), without significantly affecting the rate of retroperitoneal teratoma (21% v 22%, respectively; P = .89) or pathologic stage I disease (56% v 67%, respectively; P = .06). For patients who did not receive adjuvant chemotherapy, the 4-year progression-free probability improved significantly from 83% before 1999 (95% CI, 79% to 88%) to 96% after 1999 (95% CI, 91% to 100%; P = .005). Elevated postorchiectomy STM (P < .0001), clinical stage (P = .0002), and pre-1999 RPLND (P = .05) were independent pretreatment predictors of progression.

CONCLUSION

Excluding patients with CS IIB disease or elevated postorchiectomy STM from primary RPLND has had a favorable impact on the extent of retroperitoneal disease and has significantly reduced the risk of relapse after RPLND. For patients with normal STM and CS I to IIA disease, the low rate of systemic progression and 22% incidence of retroperitoneal teratoma supports RPLND as the preferred primary intervention.

Relapse-Free and Overall Survival in Patients With Pathologic Stage II Nonseminomatous Germ Cell Cancer Treated With Etoposide and Cisplatin Adjuvant Chemotherapy

Purpose

To assess the long-term relapse-free survival and overall survival of patients with stage II nonseminomatous germ cell tumor (NSGCT) who received two cycles of adjuvant etoposide and cisplatin (EP) after primary retroperitoneal lymph node dissection.

Patients and Methods

Eighty-seven patients with completely resected pathologic stage II NSGCT were treated with adjuvant EP chemotherapy. Adjuvant EP consisted of two cycles of etoposide (100 mg/m2) plus cisplatin (20 mg/m2) per day, administered days 1 to 5 at a 21-day interval.

Results

Ten patients (11%) had pN1 disease, 73 (84%) had pN2 disease, and four (5%) had pN3 disease. Eighty-six patients received two cycles of EP, and one patient received an additional two cycles of EP after a transient marker increase after his first cycle. Eighty-seven patients are alive, and 86 patients (99%) remain relapse-free at a median follow-up of 8 years (range, 0.9 to 13.5 years).

Conclusion

Two cycles of adjuvant EP is highly effective in preventing relapse in patients with pathologic stage II pN1 and pN2 NSGCT. An alternative treatment strategy is surveillance with full-course chemotherapy at relapse. Because there is a higher risk of relapse for patients with pN2 disease, these patients are offered adjuvant chemotherapy.

Laparoscopic versus open retroperitoneal lymph node dissection: a cost analysis

PURPOSE

Laparoscopic retroperitoneal lymph node dissection is significantly less morbid than open retroperitoneal lymph node dissection but it is generally more costly due to longer operative time and disposable equipment. In response to budgetary pressure at our large county hospital we identified the cost components of laparoscopic retroperitoneal lymph node dissection that could be targeted to decrease procedure costs before expanding our laparoscopic retroperitoneal lymph node dissection program.

MATERIALS AND METHODS

A comprehensive literature review of open and laparoscopic retroperitoneal lymph node dissection was performed and certain parameters were abstracted, including operative time and equipment, hospital stay, perioperative complications and surgical success rates. Using these data the projected overall cost and individual cost centers at our institution were compared for open and laparoscopic retroperitoneal lymph node dissection. Decision tree analysis models were devised to estimate the cost of each treatment using commercially available software. We performed 1 and 2-way sensitivity analysis to evaluate the effect of individual treatment variables on overall cost. Base case analysis involved a young man with clinical stage I nonseminomatous testicular cancer who was a candidate for retroperitoneal lymph node dissection.

RESULTS

Based on a review of the costs at our institution open retroperitoneal lymph node dissection was a less costly procedure at $7,162 versus $7,804 for the laparoscopic approach. The slight cost superiority of the open approach was due to significantly lower costs associated with operating room time and equipment. On the other hand, the laparoscopic procedure showed a cost advantage for hospital stay. On 1-way sensitivity analysis laparoscopic dissection was less costly when operative time was less than 3.6 hours, hospitalization was less than 2.2 days or laparoscopic equipment costs were less than $768. On 2-way sensitivity analysis the laparoscopic approach was cost advantageous when performed in less than 5 hours or when the patient was discharged home within 2 days postoperatively.

CONCLUSIONS

The primary cost variables for surgical treatment for testicular cancer include operative time, hospital stay and equipment cost. According to published data and decision tree analysis open retroperitoneal lymph node dissection is slightly less costly (less than $650) than laparoscopic retroperitoneal lymph node dissection for the surgical treatment of clinical stage I nonseminomatous testicular cancer at our institution. Our model identifies several measures that can be applied at any institution to render laparoscopic retroperitoneal lymph node dissection economically superior to the open approach.

Current status of retroperitoneal lymph node dissection and testicular cancer: when to operate

BACKGROUND

Historically, retroperitoneal lymph node dissection (RPLND) has been used in the therapy of both low-stage and high-stage testicular cancer after chemotherapy. As other therapies have developed, the role of RPLND has also evolved.

METHODS

The authors review the current indications for RPLND in the therapy of testicular cancer.

RESULTS

Metastatic testicular cancer can be cured in 50% to 75% of cases by surgical removal using RPLND, depending on the volume of metastasis. In postchemotherapy disease, the surgical removal of teratoma or carcinoma also confers a therapeutic benefit to the patient.

CONCLUSIONS

The therapeutic capability of RPLND in low-stage testicular cancer is underappreciated. In postchemotherapy disease, this therapeutic capability is retained if the patient has carcinoma or teratoma in the metastatic tumor. In postchemotherapy disease, efforts continue to appropriately select patients preoperatively who have only fibrosis and necrosis in the specimen and therefore do not derive therapeutic benefit from RPLND.

Testicular cancer

A report of a 5-year survival rate of 39% for all patients with testis cancer in Kenya contrasts sharply with the 62% 5-year survival rate after tandem high-dose chemotherapy in first-line salvage of metastatic nonseminoma, and this figure provides a stark reminder of the differences in level of health care in the world. Nothing matches, however, the international significance of the success of Lance Armstrong in winning the Tour de France for the second time. It brings home the message of how complete the cure of this disease is and the need for more to be done to educate people about this success and encourage us to seek to discover the scientific basis for why this cancer is so different from all other cancers. The discovery that Lance Armstrong's brain metastases were totally necrotic at day 21 after the first treatment, taken with a report on the use of day 21 computed tomograph response to predict outcome, reinforces that message. With a second report suggesting that there are regions of the world that may have escaped the environmental damage to fertility that is now increasingly accepted as the most significant risk factor for development of this disease, we also need to remember the importance of germ cells as a weather vane of the environment. The first breakthrough in identifying a specific genetic region on the X chromosome with susceptibility to germ cell cancer of the testis by its association with development of undescended testis was one of the scientific landmarks of this past year. Clinically, with such high cure rates after salvage treatments, most of the controversy focuses now on early management of this disease. Debate continues regarding the need for orchidectomy or node dissection before chemotherapy in patients with metastases. There is also considerable debate concerning the need for any adjuvant treatment in stage 1 disease, whether surgical, chemotherapeutic, or radiotherapeutic. With reviews on late events highlighting the possibility that cisplatin dosage may be critical in synergizing with etoposide in causing leukemia and late cardiovascular events and reports suggesting that circulating cisplatin can be detected in the plasma as long as 20 years after treatment, the message of the year is clearly how to safely minimize the amount of treatment.

Stage I non-seminomatous germ-cell tumours of the testis: identification of a subgroup of patients with a very low risk of relapse

There is no consensus about a reproducible prognostic model capable of distinguishing between clinical stage I non-seminomatous germ cell tumour (NSGCT) carrying a high and low risk of relapse. The aim of this study was to assess the prognostic value of histological parameters in patients with stage I NSGCT undergoing surveillance after orchiectomy. We retrospectively evaluated tumour specimens from 88 consecutive stage I NSGCT patients undergoing surveillance in our institution between 1984 and 1996. 24 patients relapsed (27%). Multivariate analysis singled out vessel invasion (VI) (relative risk (RR)=3.8; 95% confidence interval (CI) 1.4-10.4) and the presence of mature teratoma (RR= 0.2; 95% CI 0.1-0.6) as independently correlated with relapse-free survival (RFS). Patients can be classified accordingly into three prognostic groups with a low (27 patients with mature teratoma but without VI), intermediate (34 patients with both VI and mature teratoma or with neither VI or mature teratoma) and a high risk (23 patients with VI, but without mature teratoma) of relapse. Relapse rates in these three groups were 0%, 29% (95% CI: 23-35%) and 61% (95% CI: 55-67%), respectively. This prognostic index, based on two standard pathological parameters, identified a subgroup with a very low risk of relapse that represents approximately one third of stage I patients. Patients who belong to this subgroup should be managed by surveillance only, instead of retroperitoneal lymph node dissection (RPLND) or adjuvant chemotherapy.